Twist to a WAMC thread

[Sushirolls]

I got a PM from a 4th year medical student wanting to maintain some anonymity. Wondering about their chances for Psychiatry. And also the greater question of autism in practicing psychiatrists. Their stats are overall middle of the road or maybe below average. Nothing to say red flag. Person notes they have had feedback over the years that their social relatedness is at times apparent to casual interactions.

Query 1) So, are higher functioning autistic students applying to psych residency going to be hindered or not? If so, is the hinderance truly because of the autism, or simply because things are more competitive and psychiatry has to weed thru people some how, more than historically?

Query 2) Existing psychiatrists who are practicing, and have autism, any observable strengths or weakness to their practice?

Query 3) If the student has a goal to have an autism focused future practice, would they be helped to disclose on their application and their autism or not?

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[Bartelby]

1- I think it depends on whether they have autism or "autism." Recently I see a lot of clinicians, in my opinion, over diagnosing autism. They take someone with sensory sensitivity who is awkward, nerdy, and introverted and diagnose them as "on the spectrum." I think this is likely over pathologizing. The people with autism spectrum disorder I treated before this trend typically had a genuine cluelessness about other peoples' mental states, and often said things that were clearly oblivious as a result.

So in short, if the person is nerdy, awkward, and introverted but has a very good ability to empathically understand other peoples' motivations and internal states then I think they can do great in psychiatry! If they have a genuine deficit that causes them to have extreme difficulty understanding the emotions and perspectives of other people then I think it will be a real stumbling block.

2- I haven't met any psychiatrist who has made any public declaration that they have autism. If you have some vaguely autistic traits like getting fixated on a topic, liking calm and not overly-stimulating environments, and being "nerdy" then I think that can be a real strength!

3- Nope! I think saying you have autism on an application might click with a few reviewers, but it would raise yellow or red flags for significantly more. I would not recommend disclosing that.

 

[Stagg737]

Query 1) So, are higher functioning autistic students applying to psych residency going to be hindered or not? If so, is the hinderance truly because of the autism, or simply because things are more competitive and psychiatry has to weed thru people some how, more than historically?

Imo in terms of getting an interview, most likely not (unless they mess up an audition rotation d/t being difficult to work with). I could see them tanking an interview if their social skills are bad, but virtual interviewing also makes this more difficult and less obvious to pick up on as opposed to just someone who is slightly awkward. So things are probably actually better for very mildly autistic individuals now.

Query 2) Existing psychiatrists who are practicing, and have autism, any observable strengths or weakness to their practice?

I am not on the spectrum, but a med/psych resident I graduated with was and he's one of the best psychiatrists I've worked with. Incredibly caring and compassionate and his appropriate attention to details without being overly tangential (as opposed to my OCPD traits) made him an outstanding clinician who had comprehensive but concise assessments and plans. Some patients of his that I saw for urgent visits did comment on his awkwardness at times, but they still mostly loved him. Biggest problem would be if that compassion was missing and they just came off as cold or if they had co-morbid issues (ADHD, OCPD/OCD, etc) that would cause issues. Just my opinion though.

Query 3) If the student has a goal to have an autism focused future practice, would they be helped to disclose on their application and their autism or not?

Agree with above, I would advise against disclosing autism, or any diagnosis for that matter, in an application unless it was necessary to explain a red flag.

 

[Merovinge]

I think it's a great question and really hard to answer without specifically spending time with the M4. Typically if someone was on the spectrum, I would advise them to go into most other fields of medicine where some of the spectrum neurodivergence could be a positive. Classically path/rads/derm come to mind, but I've met some surgeons on the spectrum whos precision and attention to details were a clear boon, and few people cared all that much about their bedside manner since the standard of bedside is low for a lot of surgical fields.

That said, I really want to go to bat for anyone with ASD and if their heart is set on psychiatry and feel they can learn to do the work despite some difficulties understanding the nonverbal cues and such, I would not discourage them to apply. The world almost certainly needs child psychiatrists who have ASD to address this chronically underserved population. I also know a neuropsychiatrist who is probably tiptoeing onto the spectrum and they are wicked good at their job, I pray if I get some brain tumor and become catatonic they are their to care for me.

P.S. If this student does match psychiatry, they can feel free to reach out to me and I can put them in touch with a very big name in the ASD space to see about mentorship oppertunities.

 

[clozareal]

I got a PM from a 4th year medical student wanting to maintain some anonymity. Wondering about their chances for Psychiatry. And also the greater question of autism in practicing psychiatrists. Their stats are overall middle of the road or maybe below average. Nothing to say red flag. Person notes they have had feedback over the years that their social relatedness is at times apparent to casual interactions.

Query 1) So, are higher functioning autistic students applying to psych residency going to be hindered or not? If so, is the hinderance truly because of the autism, or simply because things are more competitive and psychiatry has to weed thru people some how, more than historically?

The decision to apply to psych is exclusive of applying to other specialties. It's not "should I apply to psychiatry or not." What other specialty are they considering? I would say autistic applicants would probably do better in radiology, pathology, certain surgical specialties, or something less patient focused and more task oriented/repetitive.

Query 3) If the student has a goal to have an autism focused future practice, would they be helped to disclose on their application and their autism or not?

Self-disclosure comes at a higher risk than not. If done well, it can be highly effective. If it's done awkwardly, then it can hurt.

 

[Sushirolls]

The student has a back up specialty to apply to in addition to Psych, at they have concerns about their application being competitive enough. The student expressed intent to keep applying to psych if they do land in their back up specialty. But as we all know, that's a difficult road to jump ship from one to another, now that psych has some competition. Hence the student wanting more info now. Thanks all for the contributions thus far on behalf of the student, and those about to post.

 

[clozareal]

The student has a back up specialty to apply to in addition to Psych, at they have concerns about their application being competitive enough. The student expressed intent to keep applying to psych if they do land in their back up specialty. But as we all know, that's a difficult road to jump ship from one to another, now that psych has some competition. Hence the student wanting more info now. Thanks all for the contributions thus far on behalf of the student, and those about to post.

You already know this, but for the applicant and other people who are coming to this tread, the way to improve chances of matching are to 1) apply to a higher number of programs and 2) apply broadly to areas where it's less competitive.

 

[ridethecliche]

I worked with one attending once where the medical director once described him as 'data in a sweater vest'. This was in correctional psych and the guy was a fantastic clinician. He churned through intakes like nobody's business and still had some of the most through HPI's that I've read, while still being concise.

There are a lot of settings for practice where being a good psychiatrist is a very good thing. Not all of the involve long awkward interviews and forming longitudinal relationships with patients. I don't really love the latter in an outpatient setting, but don't mind it in a few other settings (didn't mind it in a year long corrections rotation as a resident).

 

[LeaveNoTrace]

I worked with one attending once where the medical director once described him as 'data in a sweater vest'. This was in correctional psych and the guy was a fantastic clinician. He churned through intakes like nobody's business and still had some of the most through HPI's that I've read, while still being concise.

There are a lot of settings for practice where being a good psychiatrist is a very good thing. Not all of the involve long awkward interviews and forming longitudinal relationships with patients. I don't really love the latter in an outpatient setting, but don't mind it in a few other settings (didn't mind it in a year long corrections rotation as a resident).

That is interesting (and very heartening). I wonder if it's not so much that autistic (even visibly autistic) applicants are being immediately round-filed but that their communication skill and confidence are scrutinized much more. Which seems fair. I know a couple autistic psychiatry residents that are, as far as I know, doing well...but I am not working with them, and only hearing one side of the story.

 

[ridethecliche]

That is interesting (and very heartening). I wonder if it's not so much that autistic (even visibly autistic) applicants are being immediately round-filed but that their communication skill and confidence are scrutinized much more. Which seems fair. I know a couple autistic psychiatry residents that are, as far as I know, doing well...but I am not working with them, and only hearing one side of the story.

I think that things are different when you have a script. You're not making small talk with patients when you're doing an eval. Maybe you'll need that skill doing private practice with a heavy therapy bent, but realistically if you just establish ground rules when you're starting your visits it's not a big deal. I worked with an ID fellow at my first job out of college and he used to tell patients he didn't talk about politics, religion, or sports (hockey). This was in beantown and was from Canada and hated the bruins.

It was pretty hilarious. I'm pretty sure he got a few pages from the admin staff during his lunch break when his team lost. I think he was either a senators or maple leafs fan.

He was decidedly not on the spectrum, but this is just to saw that you can establish some things you won't really talk about. And if you do that and folks insist on it, then that actually might give you useful clinical information.

 

[FlowRate]

Other people have addressed the overdiagnosis of "autism" and "neurodivergent" in people with low-normal social skills.

If this applicant is actually autistic (to any relevant clinical degree)--i.e. has significant difficulties with mentalization and communication--then they should not go into psychiatry. Like 2/3 of our utility as specialists is in being particularly good at those exact skills. Sure, an autistic psychiatrist might be really good at memorizing and asking rote diagnostic questions from the DSM, but that doesn't differentiate them from a motivated NP with a clipboard intake template.

 

[Merovinge]

Other people have addressed the overdiagnosis of "autism" and "neurodivergent" in people with low-normal social skills.

If this applicant is actually autistic (to any relevant clinical degree)--i.e. has significant difficulties with mentalization and communication--then they should not go into psychiatry. Like 2/3 of our utility as specialists is in being particularly good at those exact skills. Sure, an autistic psychiatrist might be really good at memorizing and asking rote diagnostic questions from the DSM, but that doesn't differentiate them from a motivated NP with a clipboard intake template.

Just for an alternative perspective, 2/3 of my utility is being particularly good at those skills. There are instances in which someone who was neurodivergent would be superior to me in the practice of psychiatry. They will not miss some details that I do miss (I'm sure it would be vice versa as well as people talk to me in a way they wouldn't to someone who struggled with communication in a neurodivergent manner) and will naturally have better immediate rapport with people who are neurodivergent/their families.

There is something deeply soothing talking to someone who is neurodivergent and you can tell only speaks the truth/does not "spin" information that just sits well with folks, particularly in our era of everything is spun/manipulated by people or algorithms. Authenticity has become worth more in recent years and I know of no subgroup of people that are more authentic than those with ASD. I loved being able to just bluntly ask a kid a question and know that I was getting their actual perspective, rather than the typical game in child psychiatry of what is actually going on here (which is frequently different than the child's self-report). In many ways, seeing kids with ASD refreshed my brain when I was practicing outpatient CAP.

Someone would certainly need to be very self-aware and seek out good supervision/training to be able to perform through a residency and fellowship, but I have no doubt they can carve out a specific outpatient practice as a child attending even with significant ASD symptoms.

 

[FlowRate]

Just for an alternative perspective, 2/3 of my utility is being particularly good at those skills. There are instances in which someone who was neurodivergent would be superior to me in the practice of psychiatry. They will not miss some details that I do miss (I'm sure it would be vice versa as well as people talk to me in a way they wouldn't to someone who struggled with communication in a neurodivergent manner) and will naturally have better immediate rapport with people who are neurodivergent/their families.

There is something deeply soothing talking to someone who is neurodivergent and you can tell only speaks the truth/does not "spin" information that just sits well with folks, particularly in our era of everything is spun/manipulated by people or algorithms. Authenticity has become worth more in recent years and I know of no subgroup of people that are more authentic than those with ASD. I loved being able to just bluntly ask a kid a question and know that I was getting their actual perspective, rather than the typical game in child psychiatry of what is actually going on here (which is frequently different than the child's self-report). In many ways, seeing kids with ASD refreshed my brain when I was practicing outpatient CAP.

Someone would certainly need to be very self-aware and seek out good supervision/training to be able to perform through a residency and fellowship, but I have no doubt they can carve out a specific outpatient practice as a child attending even with significant ASD symptoms.

Seems maybe you're ignoring that I'm speaking about someone with actual clinically-significant autism? I'm not sure that someone who is autistic ("requires support", "clinically significant impairment in functioning") would necessarily "fit" better with other people with communication difficulties. Usually, again, our skillset is often in working around other peoples' communication challenges, not doubling down on communication difficulty due to having active, similar, but not identical, problems as our patients.

You seem to be describing an "autism lite" person who is more direct than most.

I'm personally not a fan of the "neurodivergent" term because I think it's part of the trend of watering-down the diagnostic criteria for ASD and ADHD and contributes to over-pathologization of low-normal traits.

Certainly patients have varying preferences regarding physician personality/bedside manner.

Even if I grant the assumption that it's objectively true that someone who is autistic would be great at treating autistic kids, I don't think they're going to be great at other aspects of general adult/child psychiatry. In fact, they should, by definition, be impaired at the essential practice of most of psychiatry. I don't see how someone who is actually autistic is going to make up for their deficits through force of will and "self awareness" (which they, definitionally, lack in the context of "awareness of self as they relate to others, especially emotionally.")

I am curious why OP is interested in psychiatry.

 

[calvnandhobbs68]

Totally true about the ASD vs "autism/neurodivergent" concept (and whether this person has ASD or "autism") and I also really dislike "neurodivergent" as a term...I also believe it overpathologizes more normal range behaviors while also downplaying the severity and impairment of people who have significant ASD symptoms. Aren't we all "neurodivergent", what does that even mean as a concept?

I agree that the kids I see with ASD are some of my favorite patients and I do appreciate the concrete thinking/lack of social reciprocity at times....they truly don't care much what you're thinking and just tell you straight up what they want or what's going on. Like my kid yesterday who just abruptly goes "okay you can ask 1 more question, my time is up now and you should go get my parents". This is also what tends to cause problems.

However, for someone who truly has ASD they should by definition struggle in a field which relies primarily on interpersonal interactions and it should be viewed as (what it is) a disability that they will need to accommodate around. What are the typical stories of the autistic neurologists, surgeons, pathologists, radiologists, etc? Someone who is very good technically in their field likely due to their detail awareness and restricted repetitive interests but struggles mightily with cognitive flexibility and interpersonal interactions/social reciprocity to the point where it is significantly problematic, often very socially aloof, unaware or even confrontational. So as noted above, they'll need to be very self aware and have some good mentorship, probably want to get as many observed direct patient interactions as they can to get feedback on their interactions (something we could probably all use to be honest...).

 

[LeaveNoTrace]

Totally true about the ASD vs "autism/neurodivergent" concept (and whether this person has ASD or "autism") and I also really dislike "neurodivergent" as a term...I also believe it overpathologizes more normal range behaviors while also downplaying the severity and impairment of people who have significant ASD symptoms. Aren't we all "neurodivergent", what does that even mean as a concept?

I agree that the kids I see with ASD are some of my favorite patients and I do appreciate the concrete thinking/lack of social reciprocity at times....they truly don't care much what you're thinking and just tell you straight up what they want or what's going on. Like my kid yesterday who just abruptly goes "okay you can ask 1 more question, my time is up now and you should go get my parents". This is also what tends to cause problems.

However, for someone who truly has ASD they should by definition struggle in a field which relies primarily on interpersonal interactions and it should be viewed as (what it is) a disability that they will need to accommodate around. What are the typical stories of the autistic neurologists, surgeons, pathologists, radiologists, etc? Someone who is very good technically in their field likely due to their detail awareness and restricted repetitive interests but struggles mightily with cognitive flexibility and interpersonal interactions/social reciprocity to the point where it is significantly problematic, often very socially aloof, unaware or even confrontational. So as noted above, they'll need to be very self aware and have some good mentorship, probably want to get as many observed direct patient interactions as they can to get feedback on their interactions (something we could probably all use to be honest...).

I am curious: have you ever seen any autistic psychiatrists that you know of? I know a couple. One who didn't talk till she was eight (!) but then went on to a good medical school and a great psych residency on the West Coast.

 

[romanticscience]

I am curious: have you ever seen any autistic psychiatrists that you know of? I know a couple. One who didn't talk till she was eight (!) but then went on to a good medical school and a great psych residency on the West Coast.

In my psychoanalytic training, I heard that empathy can make being a good psychoanalyst difficult (i.e., the best analysts were kind of a-holes or cold). I'm talking OG lie on the couch thrice weekly psychoanalysis, where the analyst might not speak for months. I'd explode if I couldn't engage with a patient like that and for that long. Hence, my draw is toward the more supportive side of the psychodynamic continuum or other therapies altogether.

The rationale is that psychoanalysis properly requires an abundant amount of therapeutic abstinence- technical neutrality. So, points for ASD. An antidote to counter-transference acting out?